An in-depth look at the World Health Organization policy brief that aims to reduce the overall cost of care.
BY Salwa Hindawi | 2023
The term Patient Blood Management (PBM) was first used in 2005 by Professor James Isbister, an Australian haematologist, who realised that the focus of transfusion medicine should be changed from blood products to the patients. Countries around the world are facing challenges in maintaining the supply of safe blood and blood products and their appropriate use.
The World Health Organization (WHO) published a policy brief on the urgent need to implement patient blood management in all member state countries with the aim to create awareness about the global disease burden of iron deficiency, anaemia, blood loss, and bleeding disorders; as well as to create a sense of urgency for healthcare authority and all staff working in blood transfusion chain on implementing patient blood management.
Anaemia in the general population affects an estimated 1.95 to 2.36 billion individuals worldwide, with the highest prevalence in low- and lower middle-income countries (LICs and LMICs), Iron deficiency anaemia (IDA) alone affects an estimated 1.24 to 1.46 billion people. Twice that number may suffer iron deficiency without anaemia or other micronutrient deficiencies that can lead to anaemia.
Large multicentric observational studies and randomised controlled trials demonstrated that patient blood management significantly improves morbidity, mortality, and the average length of hospital stay while reducing the overall cost of care. The expected improvements in outcomes and cost savings as well as more efficient use of (blood) resources were identified as the core drivers. The need for changing work practice and for collaboration and communication and the lack of experience with patient blood management is rated as the most important barriers due to a lack of awareness among both patients and healthcare professionals.
Patient blood management implementation requires a change in culture and behaviour, structural adjustments in health services delivery and redirection of scarce resources, active working hospital transfusion committee. Studies have shown that implementation of PBM programme can lead to reductions in length of stay, the incidence of infection, and re-admission rates for postoperative complications in patients not receiving a transfusion.
Patient blood management is considered an essential part of patient management in developed countries. The programme stresses the implementation of an evidence‐based multidisciplinary approach to optimising the care of patients who might need a transfusion. It should review patient blood management and utilisation practices in a prospective, concurrent, and/or retrospective manner aiming for improving patient outcome.
The programme will be responsible for, but not limited to, oversight and monitoring of:
- Physician blood ordering.
- Preoperative optimisation of coagulation.
- Preoperative anaemia management and autologous donation.
- Intraoperative patient blood management techniques.
- Techniques to reduce blood loss.
- Use of medications to decrease blood loss.
- Postoperative strategies and patient outcomes.
- Routine venipuncture and blood loss.
- Massive transfusion.
- Blood utilisation.
The programme should develop educational materials for hospital staff (healthcare professionals) and patients. The educational programme includes:
- Clinical guidelines, risks and benefits of blood transfusion.
- Anaemia diagnosis and management.
- Massive transfusion protocol and bleeding management.
- Review the alternatives to blood transfusion.
- It also involves methods for improving blood use such as:
- Evidence-based transfusion thresholds.
- Choosing wisely campaign for red blood cell transfusion.
- Pre-operative anaemia management for elective surgery (e.g. oral or intravenous iron, or erythropoietin).
- Antifibrinolytics to reduce blood loss (e.g. aminocaproic acid or tranexamic acid).
- Intra-operative autologous transfusion (cell salvage).
- Anaesthetic management (e.g. autologous normovolemic, haemodilution, controlled hypotension and normothermia).
- Surgical method (e.g. newer cautery methods topical haemostatic and sealants).
- Reduce phlebotomy blood loss (e.g. use microcontainers and reduce unnecessary laboratory tests).
- Point of care testing (e.g. thromboelasography).
The five main beneficiary groups of patient blood management
- Individuals living with anaemia or at risk of developing anaemia, including individuals with isolated iron deficiency, and those with bleeding or blood loss;
- Healthcare professionals including general practitioners, family doctors and nurses, speciality consultants, surgeons and hospital-based clinicians;
- Healthcare institutions and hospitals;
- Health insurers and insurance organisations;
- Health authorities at the federal and jurisdictional levels, including public healthcare
- Systems in general.
Patient blood management is not anti-transfusion, it is more than this. It can be considered personalised therapy or a PBM plan for specific patients at specific times with the active participation of the patient. The introduction and implementation of Patient Blood Management programme in all hospitals will contribute a lot to patient safety and quality of blood transfusion services provided to our customers in developing countries.
Salwa Hindawi, MSc, FRCPath, CTM is the Chief Scientific Officer of Saudi Society of Transfusion Medicine, and Professor of Haematology and Transfusion Medicine at King Abdulaziz University, Jeddah, Saudi Arabia.